Impacts of counseling on knowledge, attitude and practice of medication use during pregnancy

Hospital based, pre-post interventional study was conducted at OBG (Obstetrics and Gynecology)Ward of Manipal Teaching Hospital, Fulbari, Kaski, Nepal from September 2013 to February 2014. A total of 275 women who met the inclusion criteria were included in the study.

Simple purposive sampling technique was applied.

Data was collected using a structured questionnaire consisting of 15 questions subdivided into 7 related to knowledge and 4 each for attitude and practice. For knowledge section, each question was provided with three alternatives and scores were given as: yes = 2, no = 0, uncertain = 1. The maximum total score for this section was 14. Five-point likert scale was used for accessing attitude and practice scores and scoring was given as: strongly agree = 5, agree = 4, uncertain = 3, disagree = 2, strongly disagree = 1. The maximum total score for these sections were 20 each. Thus, the maximum total score for the questionnaire was 54.

The questionnaire was developed with reference to relevant literature reviews and expert consultation to match the scope of the study. The initially drafted questionnaire was distributed to the pharmacy experts, professors and OBG physicians of the hospital and their opinions and suggestions regarding the content, relevance, and appropriateness of the items in the questionnaire were utilized to prepare the final version (shown in Additional file 1). This questionnaire was also converted to the local Nepali language. Initial pilot study was conducted in 20 pregnant patients for pre-testing of the questionnaire with all the KAP questions. The collected responses were analyzed for the content validity with SPSS. Overall Cronbach’s alpha value of 0.857 showed that the questionnaire was reliable [19].

The questionnaire was distributed to participants after they received their medicines from the hospital pharmacy. The purpose and nature of the study was clearly explained to every individual (and their parents/spouse wherever applicable). The participation was voluntary and written informed consent was obtained from all the participants prior to data collection. After collecting the demographic data, the participants were asked to tick their most appropriate response with respect to each question and illiterate were assisted verbally. Based upon their responses the participants were then counseled regarding proper medication during pregnancy. Educational package for the pregnant included verbal counseling and face to face interaction. The follow up date of the patients were noted.

The same questionnaire was distributed again to the participants when they came for follow up. Their responses were measured before their visit to the physician. All patients were waited on their voluntary follow-up and no attempt was made to call the patients that did not show up during their specified follow-up time given by the physician. The maximum waiting time for the participants was arbitrarily set to ten days beyond the allocated follow up date. This was to make sure that participants might have some unforseen circumstances which prevented them to make up at the hospital on their allocated date and time. The collected data before and after counseling were then analyzed.

Demographic characteristics of participants including age, trimester, gravidity, occupation and level of knowledge were analyzed with the descriptive statistics using mean, standard deviation, median, range, frequency and percentage. The association of knowledge, attitude and practice scores with relation to demographics was analyzed using Kruskal Wallis test and the impacts of counseling was measured by Wilcoxon Rank Test. Microsoft Excel 2007 and SPSS version 22 were used for the data analysis.

Majority of the patients in the study were from the age group 20-24 (43.2%). Of the study population, 58.6% were from third trimester and 59.4% were primigravida. More than half of the women were housewives (61.1%) and majority of the women had a University degree. The demographic detail is shown in Table 1.

It was seen that before counseling 68.1% of the patients knew about their complications, 46.3% could tell the name of medicine prescribed, 21.8% had knowledge of the use of prescribed medicines, 48.9% knew that medicines could cause adverse effects, 65.9% knew all medicines might not be safe during pregnancy, 71.6% had a knowledge that unnecessary medicines could harm mother and fetus and 30.6% knew that unwanted medication during pregnancy could affect fetal organogenesis and development. With respect to attitude questions, 75.6% believed that they should ask about their complications and medicines with physicians or pharmacists, 67.3% agreed that they should immediately notify any adverse effects to physician, nurse or pharmacist, 62% believed that they should not take unnecessary medications during pregnancy and 75.9% had a positive attitude that unnecessary harms due to medications can be minimized by consultation with health care professionals. Likewise, in relation to medication practice habit it was seen that 64.2% of the patients had a habit of self medication, 75.5% had changed this habit after being pregnant. Only 10.3% of the respondents had a habit of asking about safety of medication during pregnancy and 54.6% used to take medications exactly as prescribed (proper time, duration, refill, etc.). The responses to individual questions are detailed in Additional file 2. The knowledge, attitude and practice scores of the respondents before counseling are presented in Table 2.

Kruskal Wallis test was run at 95% confidence interval to see the difference in baseline (before counseling) knowledge, attitude and practice scores of pregnant women with respect to their demographic variables. It was seen that there was no significant difference in the baseline KAP scores with respect to age, trimester and gravidity whereas KAP scores with respect to occupation and level of education were statistically significant as presented in Table 3, Table 4 and Table 5.

After counseling it was seen that there was significant increase in the knowledge, attitude and practice scores of the respondents. When asked on follow-up visits after initial counseling, 91.3% knew about their complication, 69.9% could tell name of medicines prescribed, 46.3% elaborated the use of medicines and 93%, 100%, 99.1% and 95.6% successively replied that medicines can show adverse effects, all medicines might not be safe during pregnancy, unnecessary medicines during pregnancy can affect health of mother and fetus and unwanted medications during pregnancy can affect fetal organogenesis and development. Similarly, with respect to their attitude, 93.9%, 95.2%, 98.7% and 97.4% respectively believed that they should ask about their complication and medication, notify any drug related adverse effects, not take unnecessary medicines during pregnancy, and potential medication related harms can be prevented by consultation with health care professionals. As with medication practice habit, after counseling percentage of respondents taking medicines without consultation significantly reduced to 2.2%, 90.9% changed their medication taking habits, 25.3% started asking about medication safety during pregnancy and 88.7% adhered to proper medicine use. The detailed responses after counseling are presented in Additional file 2. The knowledge, attitude and practice scores after counseling are summarized in Table 6.

The study was limited to a single hospital and specific geographic area of Nepal. The sample size thus might not be considered sufficient so as to generalize the findings of the study to be representative of total Nepalese pregnant women.